Attention: All Providers
Holiday Observance

The Division of Medical Assistance (DMA), First Mental Health, Medical Review
of North Carolina and EDS will be closed on Tuesday, July 4, in observance of
Independence Day.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Dental Providers
Changes to the Dental Program Effective July 1, 2000

The American Dental Association (ADA) updated the ADA claim form and the Current
Dental Terminology Users Manual (CDT-3) for the year 2000. The implementation
date for the 1999 ADA claim form is July 1, 2000. A transition period of three
months will allow the 1994 and the 1999 claim forms to be accepted from July
1, 2000 through September 30, 2000. Effective October 1, 2000, any claims or
prior approval requests received on the 1994 claim form will be returned to
the provider.

Updated North Carolina Medicaid Dental Services Manuals were distributed to
providers at the dental workshops that were held in May. In June new manuals
were mailed to all dental providers who were unable to attend a dental workshop.
Refer to a copy of the new manual for instructions on completing the 1999 claim
form.

Procedure Code Updates

Updates to the CDT-3 contain revised procedure code descriptions, procedure
code deletions, and new ADA procedure code additions. Also, to be more consistent
with billing of oral and maxillofacial surgical codes that are billed by physicians,
many ADA codes have been recoded to CPT codes (from the Physicians' Current
Procedural Terminology). The N.C. Medicaid Dental program will implement the
changes listed below.

The following codes are end dated effective with dates of service after
July 1, 2000:

Code

Description

D7470

Removal of exostosis - maxilla or mandible

D7840

Condylectomy

D7850

Surgical discectomy, with/without implant

D7860

Arthrotomy

D7865

Arthroplasty

D7870

Arthrocentesis

D7872

Arthroscopy - diagnosis, with or without biopsy

D7873

Arthroscopy - surgical: lavage and lysis of adhesions

D9240

Intravenous sedation base rate (no time involved)

Y9241

One unit intravenous sedation = 15 minutes

The following codes are added for dental providers effective with date
of service July 1, 2000:

The requirement for a service code was removed effective July 1, 2000. Previously,
the service code (1, 2, or 3) was entered in the "for administrative use only"
column (beside the fee on the ADA claim form) to indicate if the service was
rendered as a routine, prior approved, or emergency service.

Procedure code indicators are listed in the North Carolina Medicaid Dental
Services Manual to offer a quick reference to determine if a procedure requires
prior approval. These indicators are defined below:

Indicator

Key

Definition

R

Routine Service

Prior approval is not required

EM

Emergency Service

The nature of the emergency must be documented
in the recipient's chart as well as on the claim form

PA

Prior Approved Service

Prior approval is required

The following code indicators were revised as a result of removing the
service code requirement:

Revision of Billing and Reimbursement for General Anesthesia and Intravenous
Sedation

To be consistent with the ADA descriptions, billing and reimbursement was changed
for general anesthesia and intravenous sedation effective with date of service
July 1, 2000. The following charts will show examples of one hour of general
anesthesia and intravenous sedation:

Code

Description

Reimbursement

D9220

General anesthesia - first 30 minutes

$112.99

D9221

General anesthesia - each additional 15 minutes

$26.40

D9221

General anesthesia - each additional 15 minutes

$26.40

Total

1 hour of general anesthesia

$165.79

Code

Description

Reimbursement

D9241

Intravenous sedation/analgesia - first 30 minutes

$94.14

D9242

Intravenous sedation/analgesia - each additional 15 minutes

$20.67

D9242

Intravenous sedation/analgesia - each additional 15 minutes

$20.67

Total

1 hour of intravenous sedation

$135.48

Orthodontic Case Completion and Code for Final Claim Payment

Effective July 1, 2000, the following procedure code will be used for final
claim payment when orthodontic treatment is complete and less than 23 maintenance
visits were paid:

Procedure Code

Description

D8680

Orthodontic retention (removal of appliances, construction
and placement of retainer(s))

limited to recipients under age 21

once in a lifetime service

only use for final claim when orthodontic treatment is complete
and less than 23 maintenance visits were paid

requires a post treatment summary

retainers are not covered as a separate procedure

Providers are allowed payment for the banding and 23 monthly maintenance visits.
Payment received for banding constitutes about one third of the maximum allowed
for the entire treatment. The balance is paid incrementally with each periodic
maintenance visit.

In rare instances, it may take fewer than 23 visits to complete treatment.
In such cases, a provider may submit a final claim for payment of the balance
of remaining visits. Complete the 1999 ADA claim form for procedure code D8680
(orthodontic retention). EDS will manually price the claim, based on the number
of remaining visits.

If fewer than 12 maintenance visits were paid, record review is required to
substantiate the final claim payment. If it is determined that treatment was
not "completed", but rather "terminated", the final payment will not be allowed.

At case completion, submit a final claim and a written post treatment summary,
which includes the results of the treatment and assessment of the recipient's
cooperation. It is important that we receive a post treatment summary in order
to complete our case records. If fewer than 12 maintenance visits paid, attach
copies of the recipient's chart notes. The final orthodontic claim will not
be paid unless a post treatment summary is also submitted. A sample of the Orthodontic
Post Treatment Summary is printed in the May 2000 North Carolina Medicaid Dental
Services Manual on page 148. Copies of the summary will be accepted. The Orthodontic
Post Treatment Summary and final claim should be sent to:

Public Health and Medicaid are working to revise the reimbursement mechanism
for billing Medicaid dental services by Public Health Department dental facilities.
This is a joint endeavor fostering more efficient delivery of dental services
to the citizens of the state. This revision is effective with date of service
October 1, 2000.

Updated North Carolina Medicaid Dental Services Manuals were distributed to
providers at the dental workshops in May. In June new manuals were mailed to
all dental providers and Public Health Departments that were unable to attend
a dental workshop.

Refer to future Medicaid bulletins for updates on dental issues, including
additional workshops that may be scheduled. The workshops are designed to provide
Medicaid Dental Program and billing information needed to make this transition.

The Resource Based Relative Value System (RBRVS) designation for Patient demand
single or multiple event recording with presymptom memory loop,CPT 93268,
does not allow for a technical and professional component. Effective July 1,
2000, the technical and professional components are not separately reimbursed
by North Carolina Medicaid.

Carolina ACCESS (CA) primary care providers (PCPs) are responsible for coordinating
the care of enrollees listed on their monthly enrollment report. New patients
enrolled with the practice may not have an established medical record with the
practice before requiring medical care. It is at the discretion of the PCP to
authorize payment of medical services at other medical sites for their Medicaid
Carolina ACCESS enrollees who have not contacted them for the purpose of establishing
a patient/provider relationship.

The Carolina ACCESS program is creating strategies and implementing procedures
for contacting patients to assist them in getting established with their PCP.
The Division of Medical Assistance (DMA) encourages PCPs to use the enrollment
report to identify new patients enrolled with their practice and welcome them
to the practice. The local managed care representative will be working closely
with PCPs and CA patients in this effort.

It is a requirement of the Carolina ACCESS program that your practice make
appointments available in a timely manner for the enrollee to make the initial
visit. This will help in achieving the goals of creating medical homes for Medicaid
recipients and creating a system of coordinated quality care.

The CA program appointment availability standards are as follows:

Emergency *:

Immediately upon presentation or notification

Urgent**:

Within 24 hours

Routine sick care:

Within 3 days

Routine well care:

Within 90 days 15 days in case of pregnancy

Telephone medical advice:

24 hours a day with 1-hour response time after
office hours

*Emergency Medical Condition is defined as:

A medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that in the absence of immediate attention,
the medical condition could reasonably be expected to result in:

Placing the health of the individual (or with respect to a pregnant woman,
the health of the woman or her unborn child in serious jeopardy)

Serious impairment to bodily functions

Serious dysfunction of any organ or part

With respect to a pregnant woman who is having contractions:

That there is inadequate time to effect a safe transfer to another hospital
before delivery

That transfer may pose a threat to the health or safety of the woman
or the unborn child

** Urgent conditions are defined as a medical condition that warrants medical
attention and intervention within 12-24 hours. If medical care is not rendered,
the "urgent" condition could seriously compromise the patient's condition and
outcome for a full recovery.

This article is being published subsequent to inquiries from Medicaid recipients
about Medicaid coverage and access of diabetic supplies.

Both DME and home health providers may furnish the following diabetic supplies
to Medicaid recipients:

CODE

DESCRIPTION

A4253

Blood glucose test strips for use with monitor

A4258

Spring-powered device for lancet

A4259

Lancets

W4651

Blood glucose test strips (visual strips)

W4667

Insulin syringe with needle, 1 cc or smaller

W4675

Urine test strips for combination ketones and
glucose

W4676

Urine test strips or tablets for ketones

W4677

Urine test strips or tablets for glucose

In addition, DME providers may furnish the following diabetic supplies to Medicaid
recipients:

CODE

DESCRIPTION

W4018

Dial-a-dose insulin delivery device

W4063

Needle for use with dial-a-dose system

DME providers should refer to Section 6 of the North Carolina Medicaid
DurableMedical Equipment Manual, March 1, 1999 Reprint
and to the September 1998 Medicaid Bulletin article, "Coverage
of Diabetic Equipment and Supplies" for complete instructions for providing
diabetic supplies.

Home health providers should refer to Section 5.1.6 of the North Carolina
MedicaidCommunity Care Manual, October 1999 Revision
for complete instructions for providing medical supplies.

Enrollment in an HMO or Metrolina (formerly C.W. Williams), a Federally Qualified
Health Center, is mandatory for most Medicaid recipients in Mecklenburg County.
Recipients in Guilford, Forsyth, Davidson, Rockingham and Gaston must choose
between Carolina ACCESS or an HMO.

For information regarding participation with an HMO, please contact the specific
HMO from the telephone numbers listed above.

Julia McCollum, Managed Care SectionDMA, 919-857-4022

Attention: FQHC/RHC Providers
FQHC/RHC Visits

EDS is offering individual provider visits for Federally Qualified Health Center/Rural
Health Center (FQHC/RHC) providers. Please complete and return the FQHC/RHC
Provider Visit Request Form. An EDS Provider Representative will contact
you to schedule a visit and discuss the type of issues to be addressed.

Attention: Nursing Facility Providers
Nursing Facility Seminars

Nursing Facility seminars are scheduled for September 2000. The August Medicaid
Bulletin will have the registration form and a list of site locations for the
seminars. Please list any issues you would like addressed at the seminars. Return
the Nursing
Facility Seminar Issues Form to:

Seminars for Personal Care Services (PCS) providers will be held in August
2000. Provider numbers for PCS provider's range from 6600000-6601000. Note:
This workshop is NOT for Adult Care Home Personal Care Services (ACH-PC).
Each PCS provider is encouraged to send appropriate administrative, clinical,
and clerical personnel. An overview of the criteria for PCS coverage, service
limitation, and assessment process, including completion of the DMA-3000 PCS
Physician Authorization and Plan of Care, will be discussed. In addition, procedures
for filing PCS claims, common billing errors, and follow-up procedures will
be reviewed.

NOTE: Providers should bring their Community Care Manuals as a reference.
Additional manuals will be available for purchase at $20.00 each at the workshop.

Due to limited seating, pre-registration is required. Providers not registered
are welcome to attend when reserved space is adequate to accommodate. Please
select the most convenient site and return the completed registration form to
EDS as soon as possible. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers
are encouraged to arrive by 9:45 a.m. to complete registration.

Directions to the Personal Care Services (PCS)
Seminars

I-40 East into Wilmington to Highway 17 - just off I-40. Turn left onto Market
Street. The Four Points Sheraton is located approximately .5 miles on the left.

WINSTON-SALEM, NORTH CAROLINARAMADA INN PLAZA

I-40 Business to Cherry Street Exit. Continue on Cherry Street for approximately
2 to 3 miles. Turn left at the IHOP Restaurant. The Ramada Inn Plaza is located
on the right.

SALISBURY, NORTH CAROLINAHOLIDAY INN CONFERENCE CENTER

Traveling South on I-85:
Take Exit 75 and turn right on Jake Alexander Blvd.

Traveling North on I-85:
Take Exit 75 and turn left on Jake Alexander Blvd. Travel approximately .5
miles. The Holiday Inn is located on the right.

RALEIGH, NORTH CAROLINAWAKEMED MEI CONFERENCE CENTER

Directions to the Parking Lot:
Take the I-440 Raleigh Beltline to New Bern Avenue, Exit 13A (New Bern Avenue,
Downtown). Travel toward WakeMed. Turn left onto Sunnybrook Road and park at
the East Square Medical Plaza which is a short walk to the conference facility.
Parking is not allowed in the parking lot in front of the Conference Center.
Vehicles will be towed if not parked in the East Square Medical Plaza parking
lot located at 23 Sunnybrook Road.

Checkwrite Schedule

Electronic Cut-Off Schedule

July 7, 2000

August 4, 2000

September 1, 2000

July 14, 2000

August 11, 2000

September 8, 2000

July 21, 2000

August 18, 2000

September 15, 2000

September 22, 2000

Electronic claims must be transmitted and completed by 5:00 p.m. on the
cut-off date to be included in the next checkwrite. Any claims transmitted after
5:00 p.m. will be processed on the second checkwrite following the transmission
date.